The WHO 5 Moment Approach mentioned by Julie Storr and discussed last week in part 1 of this 2-part blog post provides detailed guidance as to exactly when health-care workers shall clean their hands. While these 5 rules should be strongly fixed in a healthcare worker's mind, we all know that unexpected events can occur regularly causing lapses in what can be called best practice and strict rules must be combined with motivation and training to overcome these potential sanitary set-backs.

This needs to be seamless, effective and as rapid as a successful comic improviser who can in the blink of an eye twist-a-phrase with convincing body language cause an audience to erupt in uncontrolled laughter. This could be called the Ready, Shoot, Aim Approach. Jokes work with audiences because, like nosocomial infections in wards, they achieve a significant degree of infectiousness and a chain of laughter or infection results. While hospital associated infections are no laughing matter, in both cases it is all a matter of critical timing and maintaining control, with improvisation on the ward floor and the comedy stage equally important. To achieve this critical timing, like the approach pioneered by the gunslinger of the old west (ready, shoot, aim), practitioner must be fully prepared for every eventuality and automatically hit the target without thinking about it i.e. it must become second nature. This brings us to the debate between the importance of education verses motivation and other factors influencing hand hygiene compliance.

While education is critical, having the proper supervision with allocation and placement of hand hygiene facilities and supplies may be even more important. Along with the gunslinger and comedian, it takes not just endless practice but the best available tools in the right place at the right time. As with the so-called first law of real estate, (location, location, location) location of hygiene supplies can promote or inhibit the ability of workers to dutifully carry out their orders. Several studies have shown that these factors can have a greater influence on hand hygiene compliance than training and education.

As further evidence of the proposition (it’s not just education) I want to present a chart showing that hand hygiene compliance is somewhat inversely related to educational level. Healthcare professionals shouldn’t take offense, as it shows children seem to have an unfair advantage in that they are easily bribed with puppets and balloons.

Thanks to numerous studies, it has been shown that higher compliance can be achieved with using multidisciplinary frameworks involving the trio of education, motivation and facility initiatives. Since it may not be just about remembering the basic hand hygiene rules, i.e. “its all about education”, we should look at what are considered “The 4 Stages of Training” taking place as healthcare workers train in the medical arts for insights. It is with this tool that we can see the difference between the logical “5 Moments Approach” and the illogical “Ready, Shoot, Aim” one.

Upon entering training there is the first stage called 1. UNCONSCIOUS INCOMPETENCE. It is here that the recruit doesn’t even realize what they don’t know. With initial training, that changes and students becomes aware of just how much they don’t know, this is stage 2. CONSCIOUS INCOMPETENCE. Hopefully this gives them the motivation to study hard and with completion of proper training, a state of 3. CONSCIOUS COMPETENCE is achieved. This is where the 5 Moments Approach comes in to play. This is at the point in which the now newly minted health care professional carries out all that they have learned in a fully competent conscious manner.

It is however at the last stage of 4. UNCONSCIOUS COMPETENCE where proper and effective hand hygiene really comes into its own. It is at this Zen state of “ready, shoot, aim” where the enlightened and actualized health care professional is fully able to apply all effective risk reduction strategies.

It doesn’t occur in a void, thoughtful reflection regarding the key underlying microbiological principles combined with proper resources and having the right timing will insure success. Once this is achieved and given the other key components of compliance a healthcare professional can take each and every unexpected circumstance and perform the correct procedure to reduce risk to the fullest extent possible given the conditions under which they are working.

And thus, we arrive full circle back to Kelly M. Pyrek’s initial proposition “Hand Hygiene Alone Isn’t Enough”. To maximize the effectiveness of hand hygiene, the synergistic action of hand and brain at the personal and institutional level is needed. In the next blog post, key components of effective multifaceted hand hygiene intervention programs yielding reduced infection rates will be discussed.